Should surgeons continue to perform acromioplasty for impingement syndrome?

The concept of the "impingement syndrome" and its treatment by acromioplasty (aka subacromial decompression, SAD) were introduced 50 years ago (see this link). 

In  Published evidence relevant to the diagnosis of impingement syndrome of the shoulder the authors pointed out that surgery for impingement syndrome of the shoulder is one of the most common orthopaedic surgical procedures. The rate with which this procedure is performed has increased dramatically. They sought high levels of evidence (Level I and II studies) in the published literature related to five hypotheses pertinent to the concept of the impingement syndrome and the rationale supporting acromioplasty in its treatment: 

(1) clinical signs and tests can reliably differentiate the so-called impingement syndrome from other conditions, 

(2) clinically common forms of rotator cuff abnormality are caused by contact with the coracoacromial arch,

(3) contact between the coracoacromial arch and the rotator cuff does not occur in normal shoulders, 

(4) spurs seen on the anterior aspect of the acromion extend beyond the coracoacromial ligament and encroach on the underlying rotator cuff, and 

(5) successful treatment of the impingement syndrome requires surgical alteration of the acromion and/or coracoacromial arch. 

None of these hypotheses were supported by high levels of evidence. 

They concluded that the concept of "impingement syndrome" was originally introduced to cover the full range of rotator cuff disorders, as it was recognized that rotator cuff tendinosis, partial tears, and complete tears could not be reliably differentiated by clinical signs alone. However, the current availability of sonography, magnetic resonance imaging, and arthroscopy now enable these conditions to be accurately differentiated, so that the nonspecific diagnosis of "impingement syndrome" can be discarded in favor of specific diagnoses such as  tendinosis, partial tears, and complete tears of the rotator cuff. The treatment for each these conditions requires careful, well-controlled clinical study.

The authors of On Patient Safety: Shoulder “Impingement”—Telling a SAD Story About Public Trust point out that acromioplasty quickly became one of the most commonly performed orthopaedic procedures; its usage increased five-fold between the 1980s and 2005 in the United States. However, evidence progressively accumulated that acromioplasty might be no more effective than physiotherapy. And the concept of "impingement syndrome" became recognized as a waste-basket term that included such diagnoses as  bursitis,  cuff tendinopathy, rotator cuff tear and  biceps tendinitis.

The author and colleagues launched the Finnish Subacromial Impingement Arthroscopy Controlled

Trial (FIMPACT) in 2005.  In Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial they concluded that arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy alone at 24 months after surgery. In reflection on this study, the British Medical Journal stated that "Subacromial decompression surgery should not be offered to patients with subacromial pain syndrome." 

The author goes on to point out that acromioplasty remains one of the most frequently performed shoulder surgeries in the world. In considering why this might be, he suggests that surgeons trust their own “experiences” with an operation more than randomized clinical trials. While experience do matter, a surgeon's experiences suffers from follow-up that is short, does not include standardized data collection, and does not include the large percentage of patients in a surgical practice do not return for follow-up. This is in contrast to the  FIMPACT trial that followed 81% of enrolled patients for 5 years and evaluated them using validated endpoints that matter to patients. Finally, the author points out that "procedures that carry greater risk (like shoulder surgery) should be superior to interventions with little or no risk (like shoulder exercises), and certainly superior to placebo interventions (such as the diagnostic arthroscopy performed in their controlled trial).

Another recent study, No evidence of long-term benefits of arthroscopicacromioplasty in the treatment of shoulder impingement syndrome: Five-year results of a randomised controlled trial  randomly divided 140 patients into two groups: 1) supervised exercise program (n = 70, exercise group); and 2) arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). While both groups were improved with respect to pain, disability, working ability, pain at night, Shoulder Disability Questionnaire and reported painful days), no statistically significant differences were found in the patient-centred primary and secondary parameters between the two treatment groups. The authors concluded that acromioplasty is not cost-effective. Structured exercise treatment seems to be the treatment of choice for shoulder impingement syndrome.

An additional observation is that acromioplasty performed in the presence of a rotator cuff tear can give rise to anterosuperior escape and pseudoparalysis as shown here: 

Because it is a major intervention with associated costs and risks, each surgical procedure requires solid evidence that supports clinically significant benefits in comparison to more benign approaches. Such support for acromioplasty does not appear to be present.

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).